Immunizations :

– Flu ( IIV or RIV) , RZV (2 doses, pt is older than 65), Tdap, PCV13 followed by PPSV 23 1yr later,

Screening:

• – Breast cancer screening ( Mammogram)- according to USPSTF women who are 50-74 years old should get screened for breast cancer plus she is at a higher risk due to mother having breast cancer
• Colon cancer (using Colonoscopy)- USPSTF recommends adults from age 50-75 years old and she fits the age group. The gold standard of colon cancer screening is colonoscopy although other options are available.
• Lung cancer screening ( using LDCT)- first discussing the pro and cons with the patient for this one first. She fits into the age group of 55 to 80 years old with a 30 pack year history who has quit within the past 15 years. Her pack years is 40 and she quit 5 years ago.
• IVP ( Intimate partner violence)- just in case since everyone is subject to abuse
• Screen for depression- she is a recovering alcoholic and her family history of an alcoholic father. This increases her risk of being depressed
• alcohol misuse- she has a history of an alcoholic father and is a recovering alcoholic herself, although she is sober for 8 years there a chance of relapse
• Obesity screening-  based on her weight of 160lb and height of 5 ft 6in this puts her at BMI of 25.8 which is overweight.   Waist circumference is also greater than 35 inches ( she is 37).
• Diabetes- A1C test first or if there is any discrepancy in the test A fasting glucose test can be done , family history of diabetes put her at higher risk ( sister has diabetes)
• Osteoporosis- according to USPSTF she meets the criteria of women 65 years and older
• Hypertension- her vitals indicate a Bp of 128/ 74 which is slightly elevated, I would first make sure this is not due to external factors such as age or stress before assuming there is something wrong.
• Hepatitis C virus infection screening- according to USPSTF she meets criteria of being born between 1945 and 1965. She is born in 1953.

 

Injury Prevention :

 

• Traffic safety- everyone should be educated about this. Especially about correct usage of seatbelts.
• drowning prevention- although she knows how to swim there is still a chance of drowning
• water safety – since she swims advise on drinking or drug consumption during aquatic recreational activity
• sports safety- since she rides a bike, advise on helmet usage, appropriate physical conditioning for sport
• firearm safety- advisable for all ages

Diet :

Her current diet can be improved in several ways , for starters I would like to address the fact of what exactly happended during the year where she gained back 15 pounds. It seemed that her weight watchers program was working for a year and half and then it stopped working. If I would be able to find out what factors led to the abrupt weight gain during the past year then perhaps I could address those issues and see if continuation of the program is appropriate. These factors can also prove to be important in the success of other dietary programs. Otherwise I would proceed to advising her to make changes in her diet. Addressing first the fact that her eating habits mostly consists of salads and prepared foods. Taking into account the amount of calories she’s consuming per day (1500-1800) and her moderately fit lifestyle her consumption of food and calories may not be the best choice. Her dietary habits consists of vegetables and salads and some sort of protein during dinner however, she should be consuming other forms of protein to maintain the processes in the body running and keeping her having energy to do her activities. Also because she is 66 years old her metabolism is going to be slower (Shimokata, H., & Kuzuya, F) hence I would advise her that being able to lose weight is not going to happen relatively fast rather in a more slower process. She mentions she finds her diet tolerable but joyless and hence that will be my prime motivation for her to begin a new diet. Making the diet more enjoyable such as perhaps cooking at home and trying new recipes or eating one or twice outside to restaurants from different ethic cultures could prove to make the diet more lively. Her repetitive routine is perhaps causing her to lose the fun of eating and therefore by trying different plates of food or making cooking food at home by trying new recipes can prove to be worthwhile. In terms of the diet itself I would recommend eating a diet that decreases her chance of diabetes since she is a greater risk of it due to her family history. Therefore, I would advise to eat more fruits then she is currently doing and to make it even more fun trying new fruits from different cultures such as papayas, jackfruit, mango, Yuzu, Ackee, rambutan among others.  I would also advise to eat more whole grains such as brown rice, whole rye bread, or quinoa.  Her diet should also consist of beans and legumes such as bean, lentils, chickpeas, alfalfa among others. It is also important to eat sources of protein to maintain her lifestyle such as lean meats, fish, skinless chicken, nonfat dairy, and nuts. She should also avoid sugar or corn syrup sweetened drinks and instead drink plenty of water. Also seeing as her partner and sons live far away and she is dependent on getting food for herself I would advise her to turn on the music and have a good time while cooking these delicious but healthy foods. A sample diet can include:

Breakfast: whole grain cereal, egg whites, bagel thins with nut butter, almonds and fruit, avocado with toast,  or a fruit smoothie with no sugar. Mix things up everyday

Lunch: tomato soup with kale and apple salad, turkey with hummus, olives, Greek yogurt, hard boiled egg with seed crackers, whole grain sandwich  with grilled vegetables and avocado, celery sticks with hummus

Snacks: fruits, sliced apples with peanut butter, roasted chickpeas, almonds, yogurt with berries (keeping in mind to vary them)

Dinner: brown rice with skinless chicken, lean meat, fish, spinach rolls, vegetable soup, low carb beef, marinated turkey breast – always keeping in mind to have small portions

Sweets: she can maintain eating her dark chocolate as rewards once a night but not twice.

Exercise:

• The current guidelines as indicated by the CDC for exercise in adults is 150 min/ week of moderate intensity OR 75 min/ wk of vigorous intensity as well as muscle strengthening about 2 or more times a week. However, because of her age I would maintain only the moderate intensity guidelines and not the vigorous intensity. Seeing as she mentions pushing herself to get enough exercise to achieve a daily calorie deficit, I would assume she does her routine daily including the long brisk walks, riding the bike, and doing workouts with her equipment, and swimming. Therefore, she meets the minimum requirements for moderate intensity as well as for muscle strengthening. The moderate intensity routine being walking briskly, swimming (assuming she does this recreationally), bicycling (assuming she does this at a speed of 5-9mph) and for the muscle strengthening using free weights and resistance bands. Other ways to make her routine more diverse could be walking to different places she is unfamiliar with, biking to local parks, swimming in various pools, changing her free weights exercises to target different muscle groups,  switching from resistance bands to resistance cords, as well as doing these activities with local friends or by joining clubs or a gym.
• Harm Reduction:

– Nutritional harm reduction- she mentions eating is a “big issue for me” / key issues were already addressed above

Brief Intervention:

• Obesity

– An obesity intervention is not necessary for this patient because she is only slightly overweight but does not meet the standards for obesity ( BMI of 25.8). The diet and exercise plan will also address any issues with her weight.

• Smoking Cessation- smoking intervention is not necessary because she has been screened before and has quit 5 years ago. I would still closely monitor her to make sure she doesn’t relapse
• Substance Use- substance intervention is not necessary because he has been sober for 8 years and has been screened. I would also still closely monitor her for relapse.

 

Resources:

https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html

https://www.aafp.org/dam/AAFP/documents/journals/afp/PreventiveHealthCareSchedule2018.pdf

https://www.cdc.gov/physicalactivity/walking/index.htm

Gardner, H. G. (2007). Office-based counseling for unintentional injury prevention. Pediatrics, 119(1), 202-206.

Shimokata, H., & Kuzuya, F. (1993). Aging, basal metabolic rate, and nutrition. Nihon Ronen Igakkai zasshi. Japanese journal of geriatrics, 30(7), 572-576.

PowerPoints: nutrition and the exercise prescription, screening and prevention (harm reduction), writing an exercise Prescription

Calandra James is a 66 year old recently retired administrator for City Harvest, a group that gathers leftover food from restaurants and distributes it to food banks and soup kitchens.  She is a recovering alcoholic (sober for 8 years) and she now describes her health as basically good, but says that she struggles with what she calls “an addictive nature”.  This has expressed itself in her history of drinking and a past history of smoking (she quit 5 years ago after a total of 40 pack-years), and more recently she has noted that her eating has an addictive aspect as well.  She says that eating is “a giant issue for me”.  She joined Weight Watchers and lost 75 pounds over a year and a half.  However, she has gained back 15 pounds of it over the past year.  She says, “I spend way too much time trying to stave off hunger, trying to keep calories to 1500-1800/day and pushing myself to get in enough exercise to achieve a daily calorie deficit (she takes long brisk walks, rides a bike to do errands, swims at the local beach during the season, and has a set of free weights and resistance bands that she uses at home).  I am trying to focus on healthful eating and respecting my body, but it’s really a struggle.”

Her family history includes an alcoholic father and brother who are still actively drinking, a mother who had breast cancer at age 52, but has been cancer free since then and is now 88, and a sister who has Type 2 Diabetes.  She has a long-term lesbian partner who lives a few towns away.  She also has 2 adult sons who live several states away.  She says she is looking forward to retirement because she hopes to find a way to relax and stop beating herself up all the time.

When you talk to her a little more about her eating habits, you learn that she does not really cook much.  She mostly eats salads and prepared foods from the grocery store.  A typical breakfast is scrambled egg whites with whole wheat toast.  Lunch is a yogurt and sliced fruit with peanut butter spread on it.  Snacks are humus and pita chips and or vegetables, and dinner is salad with some sort of protein.  She allows herself two pieces of dark chocolate (80 calories) as dessert most nights.  She says she finds her current diet tolerable, but “joyless”.

 

Other information:

BP 128/74          T 99          P 68, regular      R 18

Hgt  5 ft 6 in               Wgt   160 lbs              Waist circumference 37 in